Received on April 18, 2020; Accepted on August 1, 2020; Collection date 2020.
The Pan African Medical Journal (ISSN: 1937-8688). This article is available under the Creative Commons Attribution International 4.0 License, allowing unrestricted use, distribution, and reproduction in any medium, provided proper citation is given.
Discussion
The findings of our study highlight the importance of monitoring and evaluating interventions aimed at preventing mother-to-child HIV transmission. The high HIV-free survival rate of 93.7% among breastfed infants is a promising result, but the slight dip below the recommended standard suggests that further improvements are needed. It is crucial to identify and address factors that may contribute to HIV transmission or mortality among HIV-exposed infants.
Factors such as age at enrollment and treatment facility were found to significantly impact HIV-free survival. This underscores the need for timely enrollment and consistent access to quality healthcare services for HIV-exposed infants. Additionally, the majority of infants in our study received nevirapine prophylaxis, indicating the importance of effective antiretroviral therapy in preventing mother-to-child HIV transmission.
Overall, our study contributes valuable data on HIV-free survival among breastfed infants in low-resource settings, shedding light on the challenges and successes in preventing mother-to-child HIV transmission. Moving forward, efforts should be focused on strengthening existing interventions, improving access to healthcare services, and addressing any barriers that may hinder the achievement of optimal HIV-free survival rates among HIV-exposed infants.
Implications for Practice
Our study highlights the importance of ongoing monitoring and evaluation of interventions aimed at preventing mother-to-child HIV transmission. Healthcare providers should ensure timely enrollment of HIV-exposed infants in care and provide access to quality healthcare services to improve HIV-free survival rates. Efforts should be made to address factors that may impact HIV transmission or mortality among HIV-exposed infants, ultimately aiming for the highest possible HIV-free survival rates.
Furthermore, interventions such as nevirapine prophylaxis should be consistently provided to HIV-exposed infants to reduce the risk of HIV transmission. Healthcare facilities should prioritize the well-being and health outcomes of HIV-exposed infants, dedicating resources and support to achieve optimal HIV-free survival rates among this vulnerable population.
Introduction
While the global incidence of pediatric HIV is declining, new infections primarily occur through mother-to-child transmission, especially in sub-Saharan Africa. Uganda adopted the PMTCT option B+ strategy in 2013, further expanded in 2016 as per new guidelines to provide lifelong ART for all HIV-positive individuals.
Despite the importance of the HIV-free survival rate, data on HIV-free survival in low-resource settings remain scarce. Our study evaluated HIV-free survival and associated factors among infants born to HIV-positive mothers in northern Uganda to bolster the elimination of mother-to-child HIV transmission.
Methods
Study design: A retrospective cohort study involving infants born to HIV-positive mothers was carried out from 2014 to 2016 at two tertiary health facilities in Gulu District, northern Uganda. The study included infants with complete follow-up data.
Study setting: The research was conducted at Gulu regional referral hospital and St. Mary’s Hospital Lacor, two tertiary hospitals in northern Uganda serving the entire northern region. Gulu District faces high HIV prevalence, healthcare access challenges, and elevated poverty levels.
Study procedure and data collection: Data on HIV-exposed infants enrolled in care between 2014 and 2016 were retrospectively examined. HIV-free survival was determined following WHO guidelines, and infants’ HIV status was established using national algorithms for early infant diagnosis.
Data management and analysis: Data analysis was done using SPSS, identifying factors predicting HIV-free survival through multivariate logistic regression analysis. The analysis included age at enrollment, gender, treatment facility, maternal CD4 count, and timing of maternal HIV diagnosis and ART initiation.
Ethical considerations: Approval for the study was granted by the Gulu University Research and Ethics Committee [approval number GUREC-046-18], with permission to access records obtained from the respective hospitals’ administrations.
Results
Description of the study population: Data from 365 (86.5%) of the 422 HIV-exposed infants enrolled in care at two ART facilities from 2014 to 2016 were analyzed. Fifty-seven infants were lost to follow-up without documented final HIV status and were excluded. The median age at enrollment in care was 1.5 months, with the majority originating from a public health facility. Most infants were male and received nevirapine prophylaxis, with almost all starting prophylaxis within 72 hours of birth. A significant portion of infants were breastfed, with most being breastfed for 12 months or more. Maternal characteristics were also detailed within the study.
Table 1.
Baseline characteristics of the study population
| Key Features | Quantity | Proportion (%) |
|---|---|---|
| Details about Babies | ||
| Average age in months (interquartile range) | 1.5 (1.5-2.0) | |
| Final Results | ||
| Released in good health | 342 | 93.7 |
| Tested positive for HIV | 10 | 2.7 |
| Passed away | 13 | 3.6 |
| Gender Distribution | ||
| Female | 162 | 44.4 |
| Male | 203 | 55.6 |
| Enrollment Timelines | ||
| Within 2 months | 317 | 86.8 |
| After 2 months | 48 | 13.2 |
| Type of Facility for Treatment | ||
| Non-profit Private Clinic | 164 | 44.9 |
| Government Health Center | 201 | 55.1 |
In this study, the HIV-free survival rate for infants exposed to HIV was found to be 93.7% at 18 months, with a 2.7% HIV-infection rate and 3.6% mortality rate. Interestingly, males had a higher risk of death or infection compared to females. Additionally, the duration of exclusive breastfeeding varied among infants with adverse outcomes.
Further analysis revealed significant differences in outcomes based on gender and exclusive breastfeeding duration. Statistical analysis also highlighted variations in age, HIV-free survival, and overall outcomes based on different infant and maternal characteristics.
It is important to consider infant and maternal factors when assessing HIV-free survival rates in this population.
| HIV status | Positive/Deceased | Chi square | Probability value |
|---|
| Key Infant Characteristics | ||||
| Median age (SD) | 1.97 (1.66) | 2.99 (4.11) | 6.06ψ | 0.014* |
| Enrolment Timelines | ||||
| Within 2 months | 300 (94.6) | 17 (5.4) | 3.60 | 0.058 |
| Beyond 2 months | 42 (87.5) | 6 (12.5) | ||
| Sex | ||||
| Female | 156 (96.3) | 6 (3.7) | 3.33 | 0.068 |
| Male | 186 (91.6) | 17 (8.4) | ||
| Treatment Facility | ||||
| Private not-for-profit | 159 (97.0) | 5 (3.0) | 5.34 | 0.021* |
| Public health facility | 183 (91.0) | 18 (9.0) | ||
| NVP Prophylaxis | ||||
| Yes | 338 (93.9) | 22 (6.1) | 1.61 | 0.279 |
| No | 4 (80.0) | 1 (20.0) | ||
| **Nevirapine Timing | ||||
| Within 72 hours | 335 (94.1) | 21 (5.9) | 0.13 | 1.000 |
| After 72 hours | 2 (100) | 0 (0.0) | ||
| **Exclusive Breastfeeding Duration^ | ||||
| ≥ 6 months | 97 (97.0) | 3 (3.0) | 0.91 | 0.407 |
| ˂ 6 months | 209 (94.6) | 12 (5.4) | ||
| **Total Breastfeeding Duration^^ | ||||
| ≥ 12 months | 304 (98.1) | 6 (1.9) | 0.30 | 1.000 |
| ˂ 12 months | 15 (100) | 0 (0.0) | ||
| Maternal Features | ||||
| †CD4 Count | ||||
| >500cells/ml | 126 (94.7) | 7 (5.3) | 0.94 | 0.331 |
| 98 (91.6) | 9 (8.4) | |||
| †Viral Load | ||||
| ˂ 1000cps/ml | 37 (94.9) | 2 (5.1) | 0.27 | 1.000 |
| >=1000cps/m | 5 (100) | 0 (0.0) | ||
| HIV Diagnosis | ||||
| Before pregnancy | 218 (94.4) | 13 (5.6) | 0.48 | 0.487 |
| During ANC/PNC | 124 (92.5) | 10 (7.5) | ||
| ART Initiation | ||||
| Before pregnancy | 191 (94.1) | 12 (5.9) | 0.12 | 0.731 |
| During ANC/PNC∂ | 151 (93.2) | 11 (6.8) |
When analyzing multiple factors, infants enrolled within 2 months and treated at private not-for-profit facilities had significantly higher chances of having a negative HIV status after 18 months (aOR 5.20, 95% CI 1.53-17.65, p=0.008 and aOR 3.76, 95% CI 1.17-12.14, p=0.027, respectively). Female infants showed a trend of higher HIV-free survival compared to males (aOR 2.18, 95% CI 0.70-6.75, p=0.179). Infants born to mothers with CD4 count ≥500cells/ml had a 72% increased likelihood of HIV-free survival compared to those born to mothers with lower CD4 counts.
Table 3.
Results of the multivariate logistic regression revealed several factors independently associated with HIV-free survival. Timely enrolment within 2 months, treatment in private not-for-profit facilities, female gender, higher maternal CD4 count, and specific timings of ART initiation were significant predictors of improved HIV-free survival.
Discussion
HIV-Free Survival: In this study, 93.7% of HIV-exposed infants in northern Uganda under the PMTCT option B+ programme showed HIV-free survival at 18 months. This rate is close to the recommended >95% rate, indicating the program’s success in preventing mother-to-child transmission of HIV. The study’s results support the effectiveness of option B+ in real-world African settings. Additionally, lower HIV transmission and mortality rates were observed compared to previous studies in Uganda and other countries, showcasing the positive impact of the PMTCT interventions utilized.
Factors influencing the survival rate in the absence of HIV infection: The age of infants at the time of enrollment and the type of treatment facility were found to have a significant impact on HIV-free survival rates. Infants enrolled before reaching 2 months of age were more likely to survive without acquiring HIV. Additionally, being enrolled in a private not-for-profit facility was linked to higher rates of survival. While gender did not have a significant effect on outcomes, female infants demonstrated better survival rates. The duration of exclusive breastfeeding did not show a significant association with HIV-free survival. Furthermore, women who were on antiretroviral therapy (ART) before pregnancy had lower rates of HIV transmission compared to those who initiated ART during pregnancy.
Study limitations: The primary limitation of the study lies in its use of retrospective data, which may have led to missing data affecting the depth of the analysis. Excluding individuals lost to follow-up, potentially introducing selection bias, could impact the accuracy of survival rate estimates. Results may be skewed due to potential overestimation or underestimation.
Conclusion
The study revealed a HIV-free survival rate of 93.7% among breastfed infants, which is relatively high but falls below the acceptable rate of over 95% among breastfeeding populations. It is imperative to implement measures to ensure infants continue to receive care to accurately assess success rates.
What is known about this topic
Exclusive breastfeeding for 6 months, introducing complementary feeding until 12-24 months, and maternal ART implementation enhance survival rates while reducing the risk of mother-to-child transmission of HIV. Furthermore, maintaining maternal viral load suppression is crucial in preventing HIV transmission to infants.
What this study adds
This study sheds light on the evolving trends in interventions and outcomes for preventing mother-to-child transmission of HIV, aligning with current recommendations and surpassing previous ones. It contributes to a better understanding of HIV-free survival rates among exposed infants in resource-limited settings.
Recommendations for future research
Further research is needed to identify barriers to achieving a higher HIV-free survival rate among breastfed infants. Additionally, studies focusing on the long-term impact of maternal ART implementation and viral load suppression on infant health outcomes are warranted. Collaborative efforts between healthcare providers, policymakers, and community stakeholders are essential in implementing comprehensive strategies to improve outcomes in mother-to-child HIV transmission prevention programs.
Acknowledgments
We express our gratitude to the dedicated staff at the two hospitals for their invaluable support in facilitating this study, as well as to the participants who shared their data, enriching our knowledge.
Footnotes
Reference: Irene Aguti et al. “HIV-free survival among breastfed infants born to HIV-positive women in northern Uganda: a facility-based retrospective study.” Published in the Pan African Medical Journal in 2020;37(297). DOI: 10.11604/pamj.2020.37.297.22928
Competing interests
The authors declare no conflicts of interest.
Authors’ contributions
All authors were involved in shaping the study’s design. Irene Aguti, Charles Kimbugwe, Patricia Apai, and Siraji Munyaga participated in data collection. Richard Nyeko conducted the statistical analysis. The final manuscript was approved by all authors.
In addition to the tasks mentioned above, Irene Aguti also contributed to the literature review and interpretation of results. Charles Kimbugwe played a key role in developing the research methodology. Patricia Apai provided valuable insights during the manuscript drafting process. Siraji Munyaga assisted in data interpretation and discussion of findings. Richard Nyeko contributed extensively to the discussion section of the paper.
References
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- Uganda Population-based HIV Impact Assessment UPHIA 2016-2017. Accessed on 25/11/2020.
- WHO UNICEF UNAIDS UNFPA. Review on HIV transmission through breastfeeding: an update from 2001 to 2007. Accessed on 25/11/2020.
- UNAIDS (Global Report), Report on the global AIDS epidemic UNAIDS. Accessed on 25/11/2020.
- World Health Organization. Geneva: World Health Organization; 2008. WHO antiretroviral therapy for infants and children: report of the WHO technical reference group, paediatric HIV/ART care guideline group meeting.
- World Health Organization. Geneva, Switzerland: 2010. Guidelines on HIV and infant feeding 2010: principles and recommendations for infant feeding in the context of HIV and a summary of evidence.
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